Impact of free maternity policies in Kenya: an interrupted time-series analysis

Women's preferences for HIV prevention service delivery in pharmacies during pregnancy in Western Kenya: a discrete choice experiment

INTRODUCTION

Pharmacy-delivered HIV prevention services might create more options for pregnant women to use HIV prevention tools earlier and more consistently during pregnancy. We quantified preferences for attributes of potential HIV prevention services among women of childbearing age in Western Kenya.

METHODS

From June to November 2023, we administered a face-to-face discrete choice experiment survey to women aged 15-44 in Kenya's Homa Bay, Kisumu and Siaya counties. The survey evaluated preferences for HIV prevention services, described by seven attributes: service location, travel time, type of HIV test, sexually transmitted infection (STI) testing, partner HIV testing, pre-exposure prophylaxis (PrEP) and service fee. Participants answered a series of 12-choice questions. Each question asked them to select one of two service options or no services-an opt-out option. We used hierarchical Bayesian modelling levels to estimate each attribute level's coefficient and understand how attributes influenced service choice.

RESULTS

Overall, 599 participants completed the survey, among whom the median age was 23 years (IQR: 18-27); 33% were married, 20% had a job and worked regularly, and 52% had been pregnant before. Participants, on average, strongly preferred having any HIV prevention service option over none (opt-out preference weight: -5.84 [95% CI: -5.97, -5.72]). The most important attributes were the availability of PrEP (relative importance 27.04% [95% CI: 25.98%, 28.11%]), followed by STI testing (relative importance 20.26% [95% CI: 19.52%, 21.01%]) and partner HIV testing (relative importance: 16.35% [95% CI: 15.79%, 16.90%]). While, on average, participants preferred obtaining services at the clinic more than pharmacies, women prioritized the availability of PrEP, STI testing and partner HIV testing more than the location or cost.

CONCLUSIONS

These findings suggest the importance of providing comprehensive HIV prevention services and ensuring PrEP, STI testing and partner HIV testing are available. If pharmacies can offer these services, women are likely to access those services at pharmacies even if they prefer clinics.

Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study

BACKGROUND

Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya.

METHODS

We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns.

RESULTS

The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care.

CONCLUSIONS

Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman.

Factors associated with viral load non-suppression among treatment-experienced pre-teenage children living with HIV in Kenya: a nationwide population-based cohort study, 2015-2021

Background

Viral load non-suppression (VLNS) in children is a major public health concern because of attendant HIV disease progression and risk of morbidity and mortality. Based on a nationally representative database we present estimates of the prevalence, trends and factors associated with VLNS in Kenyan pre-teenage children between 2015 and 2021.

Methods

Kenya National AIDS & STI Control Program's (NASCOP) maintains an early infant diagnosis and viral load (EID/VL) database for all persons living with HIV who are enrolled in the country's primary care clinics for purposes of monitoring progress towards achievement of the 95% viral suppression goals. Participants were eligible if they were children living with HIV (CLHIV), on combination ART (cART) treatment, and ≤12 years old. The modified Mann-Kendall trend test for serially correlated data was used to identify VLNS trends. Generalized estimating equations (GEE) with a logit link was used to assess the effects of covariates on the odds of VLNS (VL ≥1,000 copies/mL) over repeated points in time, allowing for the correlation among the repeated measures.

Findings

Between January 2015 and December 2021, 508,743 viral load tests were performed on samples collected from 109,682 pre-teenage children. The prevalence of VLNS decreased from 22.9% (95% CI 22.4-23.3) to 12.5% (95% CI 12.1-12.9), p < 0.0001, and mean age increased from 3.1 (4.2) to 8.0 (3.2) years in 2015 and 2021 respectively. A modified Mann-Kendall trend test for serially correlated data denotes a statistically significant decreasing trend (τ = -0.300, p < 0.0001) over the study period. In the multivariable GEE analysis adjusted for covariates, the odds of VLNS decreased by 11% per year during the study period, (GEE-aOR 0.89, 95% CI 0.88-0.90; p < 0.0001). Factors positively associated with VLNS were EFV/NVP-based first-line cART regimen (GEE-aOR 1.74, 95% CI 1.65-1.84, p < 0.0001), PI-based cART regimen (GEE-aOR 1.82, 95% CI 1.72-1.92, p < 0.0001), and children aged 1-3 years (toddlers) (GEE-aOR: 1.84, 95% CI 1.79-1.90, p < 0.0001). On the contrary, DTG-based cART regimen, were negatively associated with VLNS (GEE-aOR 0.70, 95% CI 0.65-0.75, p < 0.0001).

Interpretation

There is a strong evidence of decreasing viremia between 2015 and 2021. To sustain the decreasing trend, accelerating the switch from the suboptimal EVP/NVP first-line regimen to optimised DTG regimen is warranted.

Funding

U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and Clinton Health Access Initiative (CHAI).

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital

BACKGROUND

In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members.

OBJECTIVE

To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor's decision were also explored.

METHODS

Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1-3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression.

RESULTS

Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13-2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32-0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001).

CONCLUSIONS

In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya

BACKGROUND

In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives.

METHODS

We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach.

RESULTS

The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs.

CONCLUSIONS

The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya

BACKGROUND

Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.

METHODS

We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).

RESULTS

At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.

CONCLUSION

Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Trends in inpatient and post-discharge mortality among young infants admitted to Kilifi County Hospital, Kenya: a retrospective cohort study

OBJECTIVES

To describe admission trends and estimate inpatient and post-discharge mortality and its associated exposures, among young infants (YI) admitted to a county hospital in Kenya.

DESIGN

Retrospective cohort study.

SETTING

Secondary level hospital.

PARTICIPANTS

YI aged less than 60 days admitted to hospital from January 2009 to December 2019: 12 271 admissions in 11 877 individuals. YI who were resident within a Kilifi Health and Demographic Surveillance System (KHDSS): n=3625 with 4421 admissions were followed-up for 1 year after discharge.

PRIMARY AND SECONDARY OUTCOME MEASURES

Inpatient and 1-year post-discharge mortality, the latter in KHDSS residents.

RESULTS

Of 12 271 YI admissions, 4421 (36%) were KHDSS-resident. Neonatal sepsis, preterm complications and birth asphyxia accounted for 83% of the admissions. The proportion of YI among under-5s admissions increased from 19% in 2009 to 34% in 2019 (P_trend=0.02). Inpatient case fatality was 16%, with 66% of the deaths occurring within 48 hours of admission. The introduction of free maternity care in 2013 was not associated with a change in admissions or inpatient mortality among YI. During 1-year post-discharge, 208/3625 (5.7%) YI died, 64.3 (95% CI 56.2 to 73.7) per 1000 infant-years. 49% of the post-discharge deaths occurred within 1 month of discharge, and 49% of post-discharge deaths occurred at home. Both inpatient and post-discharge deaths were associated with low admission weight. Inpatient mortality was associated with clinical signs of disease severity, while post-discharge mortality was associated with the length of hospitalisation, leaving against advice and referral to a specialised hospital.

CONCLUSIONS

YIs accounted for an increasing proportion of paediatric admissions and their overall mortality remains high. Post-discharge mortality accounts for a lower proportion of deaths but mortality rate is higher than among children aged 2-59 months. Services to address post-discharge mortality are needed and should focus on infants at higher risk.

Out-of-pocket payments during childbirth in Kenya under the free maternity services: Perspectives of mothers, healthcare workers and county officials

Background: This study seeks to determine the extent of women's out-of-pocket (OOP) payments for delivery under the free maternity policy (FMP).  Methods: We conducted a convergent parallel mixed-methods study using quantitative and qualitative data collection. The study was set in three facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved exit interview (EI) surveys with mothers (n = 553) who utilised FMP delivery services and focus group discussions (FGDs) with mothers who returned for postnatal visits (6, 10, and 14 weeks). There were 21 in-depth interviews (IDIs) with county officials and healthcare workers (HCWs). Quantitative data were analysed using descriptive statistics, while qualitative data were audio-recorded, transcribed and analysed using thematic analysis.  Results: Despite the FMP being free on paper, mothers incurred OOP payments in practice. The overall mean OOP payments incurred by mothers who underwent normal delivery was 9.50 USD (SD 8.20 USD), and caesarean section (CS) was 10.88 USD (SD 15.16 USD). The main cost drivers were transport, lack of adequate supply and medications, lack of policy clarity by health workers, failure to notify the NHIF office of available clients, and ultrasound scan services. While the OOP payments were not deemed catastrophic, some women perceived it as a barrier to care as they ended up using savings or selling their assets to meet the costs. There were no patient characteristics associated with OOP payments.  Conclusions: OOP payments during childbirth in Kenya place a considerable economic burden on mothers and their households. There is need to promote awareness of the policy and provide a sustainable form of transport, especially during emergencies, through collaboration with partners. Prioritising the supply of required medication used in maternal services in the universal health care benefits package to which Kenyan citizens are entitled, or sustainably financing the FMP is crucial.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare.

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

Effects of the free healthcare policy on health services' usage by children under 5 years in Burkina Faso: a controlled interrupted time-series analysis

OBJECTIVES

This study aimed to analyse, at national level, the effects of the free healthcare policy for children on the use of health services by children under five in Burkina Faso. We hypothesised that this policy has led to an immediate and sustained increase in the use of health services for these children in the country.

SETTING

We conducted a controlled interrupted time series. Monthly data at district level, spanning from January 2013 to December 2018 and corresponding to 72 monthly data points (39 before and 33 after), were extracted from the Burkina Faso National Health Information System. The analysed dataset included data from all the 70 health districts of the country.

PARTICIPANTS

The study consisted of aggregated data from children under five as the target for the policy with children aged between 5 and 14 years old as control group.

INTERVENTION

The intervention was the introduction of the free healthcare policy for women and children under 5 years from April 2016.

OUTCOME

The primary outcome was the monthly mean rate of health services visits by children.

RESULTS

Among the children under five, the rate of visits increased of 57% (incidence rate ratio (IRR)=1.57; 95% CI 1.2 to 2.0) in the month immediately following the launching of the free healthcare policy. An increase in the rate of health facility visits of 1% (IRR=1.01; 95% CI 1.0 to 1.1) per month was also noted during postintervention. Compared with the control group, we observed an increase in the rate of visits of 2.5% (IRR=1.025; 95% CI 1.023 to 1.026) per month.

CONCLUSION

Findings suggest that the free healthcare policy increased the use of health facilities for care in Burkina Faso immediately after the implementation of the policy with a small increase in the rate overtime. Strategies to maintain the policy effect over time are necessary.

Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study

Background

Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases.

Methods

This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression.

Results

We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores.

Conclusion

We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05128-6.

The Impact of Reduced Fire Risk Cigarettes Regulation on Residential Fire Incidents, Mortality and Health Service Utilisation in New South Wales, Australia

Smoking materials are a common ignition source for residential fires. In Australia, reduced fire risk (RFR) cigarettes regulation was implemented in 2010. However, the impact of this regulation on residential fires is unknown. This paper examines the impact of the RFR cigarettes regulation on the severity and health outcomes of fire incidents in New South Wales (NSW), Australia, from 2005 to 2014. Fire department data from 2005 to 2014 were linked with ambulance, emergency department, hospital, outpatient burns clinic and mortality datasets for NSW. Negative binomial regression analysis was performed to assess the changes to fire incidents' severity pre- and post-RFR cigarettes regulation. There was an 8% reduction in total fire incidents caused by smokers' materials post-RFR cigarettes regulation. Smokers' materials fire incidents that damaged both contents and structure of the building, where fire flames extended beyond the room of fire origin, with over AUD 1000 monetary damage loss, decreased by 18, 22 and 12%, respectively. RFR cigarettes regulation as a fire risk mitigation has positively impacted the residential fire incident outcomes. This provides support for regulation of fire risk protective measures and bestows some direction for other fire safety policies and regulations.

The Effects of Health Purchasing Reforms on Equity, Access, Quality of Care, and Financial Protection in Kenya: A Narrative Review

Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities' access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.

Applying the Strategic Health Purchasing Progress Tracking Framework: Lessons from Nine African Countries

The Strategic Purchasing Africa Resource Center (SPARC) developed a framework for tracking strategic purchasing that uses a functional and practical approach to describe, assess, and strengthen purchasing to facilitate policy dialogue within countries. This framework was applied in nine African countries to assess their progress on strategic purchasing. This paper summarizes overarching lessons from the experiences of the nine countries. In each country, researchers populated a Microsoft Excel-based matrix using data collected through document reviews and key informant interviews conducted between September 2019 and March 2021. The matrix documented governance arrangements; core purchasing functions (benefits specification, contracting arrangements, provider payment, and performance monitoring); external factors affecting purchasing; and results attributable to the implementation of these purchasing functions. SPARC and its partners synthesized information from the country assessments to draw lessons applicable to strategic purchasing in Africa. All nine countries have fragmented health financing systems, each with distinct purchasing arrangements. Countries have made some progress in specifying a benefit package that addresses the health needs of the most vulnerable groups and entering into selective contracts with mostly private providers that specify expectations and priorities. Progress on provider payment and performance monitoring has been limited. Overall, progress on strategic purchasing has been limited in most of the countries and has not led to large-scale health system improvements because of the persistence of out-of-pocket payments as the main source of health financing and the high degree of fragmentation, which limits purchasing power to allocate resources and incentivize providers to improve productivity and quality of care.

Perspectives of stakeholders of the free maternity services for mothers in western Kenya: lessons for universal health coverage

Background

The strategic aim of universal health coverage (UHC) is to ensure that everyone can use health services they need without risk of financial hardship. Linda Mama (Taking care of the mother) initiative focuses on the most vulnerable women, newborns and infants in offering free health services. Financial risk protection is one element in the package of measures that provides overall social protection, as well as protection against severe financial difficulties in the event of pregnancy, childbirth, neonatal and perinatal health care for mothers and their children.

Purpose

The aim of this study was to find out the extent of awareness, and involvement among managers, service providers and consumers of Linda mama supported services and benefits of the initiative from the perspectives of consumers, providers and managers.

Methods

We carried out cross sectional study in four sub counties in western Kenya: Rachuonyo East, Nyando, Nyakach, and Alego Usonga. We used qualitative techniques to collect data from purposively selected Linda Mama project implementors, managers, service providers and service consumers. We used key informant interview guides to collect data from a total of thirty six managers, nine from each Sub -County and focus group discussion tools to collect data from sixteen groups of service consumers attending either antenatal or post-natal clinics, four from each sub county, selecting two groups from antenatal and two from postnatal clinics in each sub county. Data analysis was based on thematic content analysis.

Findings

Managers and service providers were well aware of the initiative and were involved in it. Participation in Linda Mama, either in providing or using, seemed to be more prominent among managers and service providers. Routine household visits by community health volunteers to sensitize mothers and community engagement was core to the initiative. The managers and providers of services displayed profound awareness of how requiring identification cards and telephone numbers had the potential to undermine equity by excluding those in greater need of care such as under-age pregnant adolescents. Maternity and mother child health services improved as a result of the funds received by health facilities. Linda Mama reimbursements helped to purchase drug and reduced workload in the facility by hiring extra hands.

Conclusion

The initiative seems to have influenced attitudes on health facility delivery through: Partnership among key stakeholders and highlighting the need for enhanced partnership with the communities. It enhanced the capacity of health facilities to deliver high quality comprehensive, essential care package and easing economic burden.

A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya

BACKGROUND

There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya.

METHODS

We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers ("strike group") and women who were pregnant in 2018 when there were no major strikes ("control group"). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI).

RESULTS

Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002).

CONCLUSION

We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.

Examining the implementation of the Linda Mama free maternity program in Kenya

Background

In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program.

Methods

We conducted a mixed‐methods cross‐sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in‐depth interviews (n = 104), administered patient‐exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively.

Results

Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient.

Conclusions

Our findings show that there are challenges associated with the implementation of the Linda Mama program and highlights the need for process evaluations for programs to track implementation, ensure continuous learning, and provide opportunities for course correcting programs' implementation.